Facility Evaluation Report

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management visit to inspect the facility due to new resident admission. LPA identified herself to, was greeted by, and explained the purpose of the visit to Staff Priscilla Lacson. House Managers Melanie del Rosario and Roland del Rosario arrived during the visit.

During today's visit, LPA conducted a tour of the facility and reviewed resident records. Review of Resident 1's records revealed that multiple documents, including R1's medical assessment, were not signed or dated. Additionally, R1's records did not contain a care plan from home health. LPA was unable to review staff records due to there not being any staff records according to interviews with the House Manager. Review of the facility's Guardian roster during the visit determined that Staff 1, Staff 2, and Staff 3 (S1, S2, and S3) have fingerprint clearance, however, S1-S3 are not associated to the facility roster. [House Manager was provided with an LIC811 Confidential Names List to identify staff and resident] Interviews with House Manager revealed that S1, S2, and S3 have been working at the facility for more than 5 calendar days. Therefore, deficiencies regarding resident records, staff records, and staff association are being cited per California Code of Regulations Title 22 and noted on the attached LIC809-D pages. Additionally, a civil penalty in the amount of $1,500 is being issued for staff association and noted on the attached LIC421BG form.

An exit interview was conducted with House Manager Melanie Del Rosario, whose signature below confirms receipt of a copy of this report, LIC811, LIC421BG, and the Licensee Appeal Rights (LIC9058 3/22).